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COLUMBUS (WBNS) – Mount Carmel Health System says that the federal agency responsible for patient safety and hospital oversight has accepted its plans of correction to fix issues inside buildings at Mount Carmel West, East and Grove City.

The Centers for Medicare and Medicaid Services began investigating Mount Carmel in mid-January after 10 Investigates broke the news about the patient overdose scandal. After the hospital made corrections to its pharmaceutical services, CMS removed the hospital from “immediate jeopardy” status.

But subsequent site surveys continued through March – include a more robust survey of at least 20 buildings at Mount Carmel West, East and the newly opened Mount Carmel Grove City.

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10 Investigates received the documents related to the March surveys late Tuesday afternoon. A review of them shows that inspectors found multiple issues related to fire suppression within Mount Carmel facilities – including but not limited a failure to conduct routine inspections of fire suppression equipment including sprinklers and smoke alarms.

“This has the potential to affect all 463 patients at the facility,” the CMS document noted.

Among the other areas of concern including a gashes and tears on exam pillows and tables that would leave the surface “non-cleanable.”

10 Investigates is still reviewing the documents.

Mount Carmel released a statement Tuesday regarding the ruling by CMS:

“The Centers for Medicare and Medicaid Services (CMS) has accepted our plan of correction for areas identified during an extensive review of Mount Carmel West and its associated facilities in March. Nearly all of these improvement areas relate to the physical environment of the facilities.

We have completed all of the corrective actions detailed in our plan, including requesting a temporary construction waiver for one of the findings related to the physical environment. This finding will be resolved by July 1 as part of previously scheduled work and we have ensured interim safety measures are in place until then.

We anticipate CMS will return to our facilities for a follow-up visit to assess and confirm that all appropriate actions are complete and effective. In the meantime, nothing changes our ability to treat patients covered by Medicare or Medicaid. Our top priority remains providing safe, high-quality care to our patients.”